Veterans’ Needs Assessment Veterans' Needs Assessment 1. I am a:* Veteran Spouse/Partner of Veteran Child of Veteran Caregiver of Veteran Not applicable 2. My gender is:* Male Female Transgender Female/Feminine Transgender Male/Masculine Genderqueer Pangender 3. My sexual orientation is:* Asexual Bisexual Gay Heterosexual/Straight Lesbian Pansexual Queer Questioning 4. My ethnicity is:* Hispanic/Latinx Non-Hispanic/Latinx 5. My race is: (check all that apply)* American Indian or Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White 6. My age group is:* 13-17 18-27 28-44 45-59 60-84 85+ 7. My employment status is:* Employed Retired - not disabled Retired - disabled Unemployed Under-employed Student 8. My branch of service is/was:* Air Force Army Coast Guard Marines Navy National Guard Reserves Not applicable 9. My discharge status is:* Honorably discharged Less than honorably discharged (does not affect accessing services) Active duty military Not applicable 10. My discharge was due to a medical condition: Yes No 11. I receive benefits through the Veterans Administration:* Yes No Not Applicable 12. I do or did receive benefits/services from another Veteran's assistance program:* Yes No Not applicable 13. Please describe any benefits received if you answered yes to question 12:14. My healthcare is paid through: (check all that apply) Veteran's Administration Champus/Tricare Private employer insurance Marketplace insurance Medicare Medicaid Harris Health System Federally Qualified Health Clinic (non-profit) I do not have access to any resources for healthcare 15. I have been treated for a mental health condition: Yes No 16. I have been treated for a substance use disorder: Yes No 17. I have a permanent place to live: Yes No 18. If you answered no to question 17, please describe your living situation:19. I receive these services from any source: (check all that apply) Primary care/medical Dental Vision Hearing Mental health counseling Substance use disorder counseling Case management Food Transportation - bus/rail/gas voucher Transportation - van pick-up Housing financial support Employment services Educational/Vocational training Legal assistance Budgeting/Money Management Upgrading disability assessment 20. I need these services but have not been able to obtain them: (check all that apply) Primary care/medical Dental Vision Hearing Mental health counseling Substance use disorder counseling Case management Food Transportation - bus/rail/gas voucher Transportation - van pick-up Housing financial support Employment services Educational/Vocational training Legal assistance Budgeting/Money Management Upgrading disability assessment 21. I am able to meet my financial obligations and living expenses: Yes No 22. I am able to sustain a good quality of life: Yes No 23. My most urgent unmet need is:24. I have encountered these barriers to receiving services: (check all that apply) Not aware of where to get services Transportation difficulties Discrimination Not eligible Wait lists Quality of the services available Confidentiality problems If you have already completed the Interpersonal Support Evaluation List, skip to the last question. This scale is made up of a list of statements each of which may or may not be true about you. For each statement check "definitely true" if you are sure it is true about you and "probably true" if you think it is true but are not absolutely certain. Similarly, you should check "definitely false" if you are sure the statement is false and "probably false" if you think it is false but are not absolutely certain. ISEL-12 Q1, If I wanted to go on a trip for a day (for example, to the country or mountains), I would have a hard time finding someone to go with me. definitely false probably false probably true definitely true ISEL-12 Q2. I feel that there is no one I can share my most private worries and fears with. definitely false probably false probably true definitely true ISEL-12 Q3. If I were sick, I could easily find someone to help me with my daily chores. definitely false probably false probably true definitely true ISEL Q4. There is someone I can turn to for advice about handling problems with my family. definitely false probably false probably true definitely true ISEL Q5. If I decide one afternoon that I would like to go to a movie that evening, I could easily find someone to go with me. definitely false probably false probably true definitely true ISEL Q6. When I need suggestions on how to deal with a personal problem, I know someone I can turn to. definitely false probably false probably true definitely true ISEL Q7. I don't often get invited to do things with others. definitely false probably false probably true definitely true ISEL Q8. If I had to go out of town for a few weeks, it would be difficult to find someone who would look after my house or apartment (the plants, pets, garden, etc.). definitely false probably false probably true definitely true ISEL Q9. If I wanted to have lunch with someone, I could easily find someone to join me. definitely false probably false probably true definitely true ISEL Q10. If I was stranded 10 miles from home, there is someone I could call who could come and get me. definitely false probably false probably true definitely true ISEL Q11. If a family crisis arose, it would be difficult to find someone who could give me good advice about how to handle it. definitely false probably false probably true definitely true ISEL Q12. If I needed some help in moving to a new house or apartment, I would have a hard time finding someone to help me. definitely false probably false probably true definitely true Lastly, if you would like someone to contact you about services or social support, please list your name, phone number and email.
